LPN/LVN Utilization Management Reviewer
Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.
Job title:
LPN/LVN Utilization Management Reviewer
Job Description:
We are currently hiring a LPN/LVN Utilization Management Reviewer. This role is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of client's benefits plan. The Utilization Management (UM) Reviewer is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making. The Utilization Management Reviewer has a key role in ensuring the client meets CMS compliance standards in the area of service decisions and organizational determinations. Successful candidates must have a current, valid Massachusetts clinical license in good standing.
Key responsibilities:
Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to Durable Medical Equipment/Services, Long Term Services and Supports (LTSS), and Home Health (HH)
Applies established criteria (e.g., InterQual and other available guidelines) and employs clinical expertise to interpret clinical criteria to determine medical necessity of services
Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements
Provides decision-making guidance to clinical teams on service planning as needed
Works closely with Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with Standard Operating Procedures
Ensures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policy
Works with UM Manager and other clinical leadership to ensure that departmental and organizational policies and procedures as well as regulatory and contractual requirements are met
Creates and maintains database of denied service requests
Additional duties as requested by supervisor
Standard office conditions. Some travel to clinical practices may be required.
Education:
Associate degree
MA clinical license (Physical Therapy, Occupational Therapy, or Respiratory Therapist) in good standing.
Experience:
Required: 3+ years combined clinical and utilization management experience
Strong plus: 3+ years' experience working in a health plan and/or experience with a care management platform
Skills:
Ability to apply predetermined criteria (e.g., InterQual) to service decision requests to assess medical necessity
Flexibility and understanding of individualized care plans
Ability to influence decision making
Strong interpersonal, verbal and written communication skills
Ability to work independently
Comfort working in a team-based environment
Will be required to pass credentialing process.
Hourly pending experience
Hours: Monday through Friday 9AM to 5PM Eastern Time
This is a fully remote work at home role. You must have a secure, private wok at home area with a hardwired internet connection with speeds greater than 5MB upload and 10MB download.
Sagility Offers Competitive Benefits Including:
Medical
Dental
Vision
Life Insurance
Short-Term and Long-Term Disability
Flexible Spending Account
Life Assistance Program
401K with employer contribution
PTO and Sick Time
Tuition Reimbursement
Join our team, we look forward to talking with you!
An Equal Opportunity Employer/Vet/Disability
Location:
Work@Home USAUnited States of America
Apply Now
Job title:
LPN/LVN Utilization Management Reviewer
Job Description:
We are currently hiring a LPN/LVN Utilization Management Reviewer. This role is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of client's benefits plan. The Utilization Management (UM) Reviewer is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making. The Utilization Management Reviewer has a key role in ensuring the client meets CMS compliance standards in the area of service decisions and organizational determinations. Successful candidates must have a current, valid Massachusetts clinical license in good standing.
Key responsibilities:
Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to Durable Medical Equipment/Services, Long Term Services and Supports (LTSS), and Home Health (HH)
Applies established criteria (e.g., InterQual and other available guidelines) and employs clinical expertise to interpret clinical criteria to determine medical necessity of services
Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements
Provides decision-making guidance to clinical teams on service planning as needed
Works closely with Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with Standard Operating Procedures
Ensures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policy
Works with UM Manager and other clinical leadership to ensure that departmental and organizational policies and procedures as well as regulatory and contractual requirements are met
Creates and maintains database of denied service requests
Additional duties as requested by supervisor
Standard office conditions. Some travel to clinical practices may be required.
Education:
Associate degree
MA clinical license (Physical Therapy, Occupational Therapy, or Respiratory Therapist) in good standing.
Experience:
Required: 3+ years combined clinical and utilization management experience
Strong plus: 3+ years' experience working in a health plan and/or experience with a care management platform
Skills:
Ability to apply predetermined criteria (e.g., InterQual) to service decision requests to assess medical necessity
Flexibility and understanding of individualized care plans
Ability to influence decision making
Strong interpersonal, verbal and written communication skills
Ability to work independently
Comfort working in a team-based environment
Will be required to pass credentialing process.
Hourly pending experience
Hours: Monday through Friday 9AM to 5PM Eastern Time
This is a fully remote work at home role. You must have a secure, private wok at home area with a hardwired internet connection with speeds greater than 5MB upload and 10MB download.
Sagility Offers Competitive Benefits Including:
Medical
Dental
Vision
Life Insurance
Short-Term and Long-Term Disability
Flexible Spending Account
Life Assistance Program
401K with employer contribution
PTO and Sick Time
Tuition Reimbursement
Join our team, we look forward to talking with you!
An Equal Opportunity Employer/Vet/Disability
Location:
Work@Home USAUnited States of America
Apply Now